Post-implementation Audit Research Articles

Obstetric triage improvement process using the Donabedian model of quality care: a quality improvement initiative.

Obstetric triage has become one of the most crucial innovations in the field of perinatal care in the past 15 years. In lower- middle- income countries (LMICs), the pregnant patients are seen in a conventional way based on the time of their arrival; this divergent, unbalanced and inequitable approach results in delayed initial evaluation, prolonged length of stay (LOS) and affected clinical outcomes.This project aimed at implementing an effective and efficient obstetric triage system with improved throughput and care processes within six months to facilitate timely decision making according to the individualized needs of pregnant patients.A pre-implementation audit was completed for the core evaluation of existing obstetric triage services, followed by a fishbone analysis. Following the Donabedian model for quality care, a quality improvement project was initiated to redesign the obstetric triage system. The project strategy was implemented as part of six PDSA (Plan- Do -Study- Act) cycles to optimize the structure, processes, and obstetric triage outcomes. The triage paradigm moved from time-based care delivery to priority care, and processes were improved based on Angelini’s recommendations of best practices in obstetric triage. During the initial phase of improvement, the identified outcome measures were waiting time of 5 minutes from arrival to initial assessment, LOS of 120 minutes, and acuity-based care for at least 50% of patients. A post-implementation audit was conducted to assess improvements. The results showed that the LOS at triage reduced from 240 min (4 hours) to 60 min (1 hour) within 6 months. Furthermore, wait times for triage decreased significantly to 5 min in 65% of patients, compared with 6% in traditional triage practice.The results indicate that the traditional triage model of the ‘order of arrival’ process is inefficient in providing adequate obstetric care. This quality initiative facilitated the successful incorporation of the Donabedian model and best practice triage practices and helped achieve desired outcomes of improved LOS and reduced waiting time with acuity-based care. Therefore, the design of an efficient, and the appropriate obstetric triage system can be adopted by other healthcare institutions in a local setting that can facilitate patient centric care.

Diabetes mellitus self-management education at Jimma University Medical Center: evidence-based implementation project.

Low and middle-income countries are currently enduring the heaviest global burden of diabetes and diabetes-related mortalities. Diabetes self-management education (DSME) improves patient clinical outcomes, health status, and quality of life. Lack of awareness about best practice guidelines and recommendations may be associated with increased risk of diabetes morbidity and mortality. The objective of this study was to improve knowledge and skill of healthcare providers and patients with diabetes by enhancing evidence-based practice through self-management education to increase compliance with best practice recommendations. JBI's three-phase Practical Application of Clinical Evidence System and Getting Research into Practice audit criteria of diabetes of audit management criteria were used. To understand barriers, 12 audit criteria, patient's medical record handling and educational plan according to set standards were evaluated. To mitigate the barriers, strategies of training and supportive supervision on evidence-based DSME were implemented from 20 April 2018 to 7 June 2018. Sixteen health professionals and 80 patients with diabetes participated in the study conducted in Jimma University Medical Center. Both a baseline and follow-up audit was conducted using the JBI feedback tool. The baseline audit results indicate that 3 of the 12 audit criteria recorded zero percent compliance, whereas other compliances were below 40%, representing poor compliance with the current evidence. The post implementation audit reported 100% compliance for criteria on availability of structured education plan, existence of appropriate training for staff, the presence of education regarding nutrition and medications, while for the remaining criteria on competency of staff members for delivering DSME, assessment of prior diabetes knowledge, status of documentation after each session, and the presence of appropriate referrals or booking the compliance rate was improved to 88%. Similarly, criteria on the presence of individualized education plan improved (0-75%), encountering knowledge regarding physical activity (6-75%), self-monitoring of blood glucose (4-60%), and prevention diabetes complications (10-90%). There were remarkable changes in both patients and care providers on comparison of pre-intervention and post-intervention, particularly in availability of materials, involvement of staff in self-management education, nutrition, and medication.

Improving the Time to Antibiotic Administration in Paediatric Febrile Neutropenia: Implementation of a Clinical Care Pathway in Saudi Arabia

The aim of this quality improvement practice project was to improve noted delays in the time to antibiotic administration in paediatric febrile neutropenic patients seen at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Saudi Arabia. Larrabee’s 6-step Model for Change of evidence-based practice guided the project. Clinical audit, nursing knowledge survey, comprehensive literature and international clinical guideline review were used to identify and design a clinical care pathway for paediatric febrile neutropenic patients at KFSH&RC. Post-implementation clinical audit showed a reduction in time to antibiotic administration and increased self-efficacy and knowledge among nursing staff in relation to managing the care of febrile neutropenic patients. This reflects similar improvements seen internationally in other centres following the introduction of a clinical pathway. This nursing led practice change was the first of its kind for KFSH&RC. It demonstrated that with support from key stakeholders, Larrabee’s model for evidence- based practice change can be used for introducing a nurse-led clinical care pathway in Saudi Arabia. Highlights •A new clinical care pathway introduced in Saudi Arabia improved time to antibiotic administration in paediatric febrile neutropenic patients. •Implementing a nurse-led clinical care pathway increased nurses’ confidence with managing children with febrile neutropenia and the skills and knowledge related to the accessing and delivering medication via central access devices •With key local stakeholder support evidence-based change frameworks such as that proposed by Larrabee can be used to improve nursing management in Saudi Arabia.

Diabetic foot ulcer risk assessment and prevention in patients with diabetes: a best practice implementation project.

Diabetic foot ulcer (DFU) is one of the most serious complications in patients with diabetes. Early identification of risk factors can prevent its occurrence and delay its progression. The aim of this project is to conduct an audit of DFU risk assessment protocols at a large tertiary hospital and evaluate the impact of any changes in compliance with the developed evidence-based best practice criteria. Preimplementation and postimplementation audits based on JBI's Practical Application of Clinical Evidence System were conducted at the Department of Endocrinology and Metabolism of a tertiary hospital in China. The Getting Research into Practice audit tool was used to analyze the barriers and inadequacies encountered in practice. A total of 12 nurses and 30 patients with diabetes were included in the baseline and follow-up audits. There were 15 baseline audits that indicated deficits in DFU risk assessment by nurses, with 0% compliance for three criteria and 50% compliance or less for seven others. Strategies developed by the project team to address the identified barriers to compliance were adopted, leading to significant improvement in compliance with most criteria at the follow-up audit compared with baseline with 11 criteria achieving at least 90% compliance. The project showed that regular audits of foot ulcer risk assessment can help to identify barriers to their implementation. Advising patients of their risk status can support appropriate self-care practices. Further audits are needed to implement evidence-based practices in all aspects of diabetes patient care.

Hand hygiene among nurses in pediatric blood and marrow transplantation setting: a best practice implementation project.

The aim of this project was to promote evidence-based best practice regarding hand hygiene among nurses in a pediatric blood and marrow transplantation (BMT) setting. Healthcare-associated infections (HAI) represent important complications of healthcare with potentially major impact on patient outcomes. Most HAI are transmitted through the hands of healthcare professionals (HCP) and therefore hand hygiene is the simplest, most effective and proven method for preventing HAI. However, the overall compliance rate of HCP with hand hygiene remains at a very low level. In this case, it is necessary to implement strategies to improve the compliance with hand hygiene of the HCP with the purpose of reducing HAI rates, mortality and costs, all the more so as it is known that patients with BMT have an increased risk of HAI. This best practice implementation project was based on the JBI methodological approach and included three phases of activity: a baseline audit, implementation of strategies and a follow-up audit. The project was conducted in the pediatric BMT setting of a large university hospital located in Bucharest, Romania, and the sample included 10 nurses and five relatives of pediatric patients from this ward. As a result of the implementation of strategies, improvements were observed across seven audit criteria, given that for two audit criteria out of a total of nine audit criteria compliance was maximum (100%) since the baseline phase. Moreover, the post implementation audit showed a complete compliance (100%) for six audit criteria. However, for the other three audit criteria the compliance in follow-up audit was high: 92, 85 and 80%, respectively. The strategies applied within this evidence implementation project were appropriate, so the project was a success. However, permanent actions are required to sustain changes in practice and improvements made.

Prevention of needle-stick injury among nurses in an acute ward of a hospital: a best practice implementation project.

This evidence implementation project aimed to identify barriers leading to needle-stick injuries (NSIs) and to develop implementation strategies to prevent NSIs in the acute ward of a hospital in central Taiwan. The incidence rate of NSIs was 5.6% in the acute ward of a hospital in Taiwan. NSIs commonly occur during the drawing of blood, intravenous insertion, needle recapping, or performing any procedure involving sharp medical devices. NSIs are critical occupational risks among healthcare workers, possibly leading to transmission of infectious diseases, especially blood-borne viruses, such as HIV, hepatitis B, and hepatitis C. A clinical audit was undertaken using the JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) approach. Five audit criteria that represented best practice recommendations for prevention of NSIs were used. Baseline data were collected from 177 nurses in five acute wards, followed by the implementation of multiple strategies during a 20-week period of the project. Both baseline and postimplementation audits were undertaken to determine changes in practice. According to the pre-audit concerning the use of safety-engineered injection devices and safe use and disposal of needles, there was 14-15% compliance, which indicated poor compliance with current best-practice criteria. Following the project implementation, the nursing staff were educated about the well tolerated use and disposal of sharps and the improved compliance rate ranged from 40 to 96.6%, with safety needle use increasing from 16 to 95.5%, safety needle operation procedure awareness increasing from 14 to 96%, needles not recapped after use increasing from 47 to 85%, and placing used needles in the sharps collection box increasing from 75 to 80%. This article suggests that standardized puncture prevention education and training enhanced nurses' awareness in the acute ward.

Patients performing lower limb exercises in an orthopedic ward: a best practice implementation project

The evidence-based project sought to educate patients on doing lower limb exercises within 24 h of their admissions to the ward. Patients spend most of their time in bed during their hospital stays, which imposes negative outcomes due to inactivity, such as risks of reduced muscle mass and deconditioning, which may further implicate patients' conditions. The project occurred in three phases over a period of 18 months. The project was undertaken in an orthopedic ward of an acute tertiary hospital. A preimplementation and postimplementation audit strategy using the Joanna Briggs Institute's Practical Application of Clinical Evidence System was conducted on a sample of 20 adult patients. The Getting Research into Practice framework was utilized to analyze the barriers and gaps encountered in the clinical ground. The baseline audit result revealed that only 35% of the patients received education on the exercise program and that there was poor compliance on nursing documentation of the intervention in daily note-free texts. Following the implementation, there was an improvement in nurses' documentation compliance. In follow-up audits one and two, the nurses achieved compliance rates of 60 and 90% in nursing documentation, respectively. Overall, there were improvements in provision of lower limb exercise education to patients. This project has demonstrated that patients were willing to exercise during hospitalization. Nurses play a significant role in providing early education to patients to do simple exercises. The implementation of the evidence-based project may increase the awareness of the importance of exercises to minimize hospital-acquired deconditioning and functional declines among ward nurses and patients.

Improvement in use of best practice in the care of patients with oral mucositis in a comprehensive cancer center in Iran: a best practice implementation case study.

Oral mucositis is a common debilitating complication of cancer treatments, particularly chemotherapy and radiation. The purpose of this study was to improve oral mucositis prevention and control among cancer patients through the implementation of best practice guidelines in a tertiary referral center in Northern Iran. A clinical audit design was utilized in this implementation project. A preimplementation audit was conducted against nine best practice criteria for the prevention and treatment of oral mucositis among new cases of cancer patients in November and December 2019. Fifty cancer patients and 20 nurses participated in this phase of the clinical audit. The next step included a facilitated multidisciplinary focus group identifying targeted strategies and implementing them, completed in late December 2019. A postimplementation audit was then conducted on another 50 cancer patients and the same 20 nurses in January and early February 2020. The project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice software. The preimplementation audit revealed gaps between the current practice and best practice across eight of the nine criteria. After implementing the targeted strategies, the outcomes improved across most of the criteria in the follow-up audit: 80% increase was observed in compliance of staff education, 100% increase in providing standard oral hygiene protocol in place, 64% increase in carrying out a dental examination and conducting initial oral cavity examination, and also 34% increase in conducting of ongoing oral cavity examination by a dentist, and finally 100% increase in providing preventive and therapeutic oral care regimens in place and oral pain assessment using a validated tool. The results of this project indicate that clinical auditing is an effective approach to the assessment of evidence-based care practices for oral mucositis among new cancer patients. Evidence-based oral mucositis management among cancer patients can be achieved by educating the patients and nursing staff using the newest guidelines and dentists' comprehensive dental and oral hygiene examinations.

Increasing patient participation in hand hygiene practices in adult surgical wards in a tertiary institution: a best practice implementation project

The WHO states that hospital-acquired infections may be transmitted through contaminated hands. Practicing hand hygiene using alcohol-based handrub or soap and water reduces harmful organisms. The Joanna Briggs Institute (JBI) best practice recommends empowering patients with hand hygiene knowledge and engaging their involvement to strengthen hand hygiene practices. The aim of this project was to improve hand hygiene among surgical inpatients. This evidence-based quality improvement project was conducted in three phases: the baseline audit, implementing best practice, and the postimplementation audit. Participants were patients hospitalized in three surgical wards of a 1200-bed acute care tertiary hospital. This project utilized the online JBI Practical Application of Clinical Evidence System and The Getting Research into Practice program to identify barriers and strategies. Nurses provided patients with an education pamphlet and regularly reminded them to improve their hand hygiene practices. Ninety-four patients were audited between April and June 2018. Patients' hand hygiene practices improved from 19.1% at baseline audit to 61.7% (P < 0.01) at first follow-up audit. Patients' hand hygiene improved from 48.9 to 72.3% (P = 0.03) before meals, and from 92.6 to 98.9% (P = 0.65) after toileting. The proportion of patients who received a hand hygiene information leaflet in an appropriate language increased from 64.9 to 89.4% (P < 0.01). Patients' involvement in the hand hygiene program has significantly improved their hand hygiene practices. Patient education and patient information leaflet continue to be an effective strategy to improve knowledge and practices.

Bridging the Communication Gaps from Preop to Phase II

Background Information Lack of a standard process or tool to communicate patient information and parental concerns from Preop to PACU resulted in less than optimal care for a sometimes very complex patient population. Lack of a consistent process or tool for PACU resulted in incomplete handoffs from surgical and anesthesia colleagues. Lack of a standard process for handoff from PACU RN to Phase II RN also resulted in less complete movement of information with the potential to compromise care. Objectives of Project Develop a tool to •improve communication of patient information from Preop to PACU •provide prompts to obtain more complete PACU handoffs from surgery and anesthesia colleagues •provide structure for RN to RN handoffs downstream from PACU and therefore, improve parent and patient care and satisfaction, safety and efficiency. Process of Implementation Audit current process for passing information, surveyed staff pre and post implementation of tool regarding communication gaps and handoff challenges, developed a tool, trialed and reformatted the tool based on feedback from users and post-implementation audits of the new tool. Statement of Successful Practice The use of the tool has been well adopted by the staff and surveys indicate staff feel the quality of handoffs have improved with audits indicating good use of the tool to provide patient and parent information from the preop side and improved quality of handoffs on PACU arrival which flow down the line. Implications for Advancing the Practice of Perianesthesia Nursing In the age of electronic health records this easy to use tool captures targeted specific information and provides structure for handoffs from Preop to Phase II. Processes to improve communication have been shown to improve safety and efficiency. Lack of a standard process or tool to communicate patient information and parental concerns from Preop to PACU resulted in less than optimal care for a sometimes very complex patient population. Lack of a consistent process or tool for PACU resulted in incomplete handoffs from surgical and anesthesia colleagues. Lack of a standard process for handoff from PACU RN to Phase II RN also resulted in less complete movement of information with the potential to compromise care. Develop a tool to •improve communication of patient information from Preop to PACU •provide prompts to obtain more complete PACU handoffs from surgery and anesthesia colleagues •provide structure for RN to RN handoffs downstream from PACU and therefore, improve parent and patient care and satisfaction, safety and efficiency. Audit current process for passing information, surveyed staff pre and post implementation of tool regarding communication gaps and handoff challenges, developed a tool, trialed and reformatted the tool based on feedback from users and post-implementation audits of the new tool. The use of the tool has been well adopted by the staff and surveys indicate staff feel the quality of handoffs have improved with audits indicating good use of the tool to provide patient and parent information from the preop side and improved quality of handoffs on PACU arrival which flow down the line. In the age of electronic health records this easy to use tool captures targeted specific information and provides structure for handoffs from Preop to Phase II. Processes to improve communication have been shown to improve safety and efficiency.

Maintaining oral hydration in older adults in surgical wards: a best practice implementation project.

Oral hydration is essential in older adults as poor hydration can complicate existing medical conditions and increase morbidity. Older adults in surgical wards are at risk of dehydration due to insufficient fluid consumption. The aim of this project is to ensure patients aged 65 years and above are adequately hydrated. The current project was conducted over 7 months from February to August 2019 and involved pre and postimplementation audits to ensure compliance with best practice. The Joanna Briggs Institute Practical Application of Clinical Evidence System and the Getting Research into Practice tools were used as a guide. Audits were conducted at four surgical wards with a sample of 42 patients at each audit. The measures implemented include educating nurses on the importance of oral hydration in older adult patients and labelling water jugs to encourage fluid intake among these patients. Nurses' compliance in monitoring older adult patients' daily fluid intake increased from 5 to 76% at follow-up audit (P < 0.05). In addition, the average amount of fluid consumed over 3 days increased from 858.23 to 1037.50 ml. This project demonstrated a significant increase in oral fluid intake among older adult patients during hospitalization and their understanding of adequate fluid intake. Nurses play an important role in ensuring adequate amounts of daily fluid intake by these patients.

Applying a Mixed-Method Approach to Improve On-the-Job Learning and Job Satisfaction in a Cohort of Interns at a University Hospital

Introduction: Job satisfaction is vital for the optimal functioning of medical practitioners. Herein, we report our experience of restructuring the internship program by identifying the gaps, developing, implementing strategies to overcome gaps and sharing the results of the pre-implementation and post-implementation audit, as an example for establishing a system for improving intern’s work-based learning and satisfaction in a university hospital setting.Methods: Using Kern’s six-step instructional model, a prospective mixed-method study was conducted at Aga Khan University Hospital. In phase 1 (2013) gaps were identified by evaluating various aspects of the internship program. Strategies were developed and implemented to overcome the identified gaps. In phase 2 (2014-2016) the impact of these developmental strategies was assessed.Results: A total of 65 interns, 30 residents, and 22 faculty members participated in phase I, while 71 interns participated in phase II. The reformation of orientation sessions, including practical exposure and content of sessions, opportunities to enhance hands-on experience and supervision in inpatient areas, operating rooms, supervision by fellows, supervision for hands-on procedures, career counseling, and mentorship, led to significant improvement in satisfaction. It was identified that the lack of hands-on opportunities can be overcome by surgical skills-based workshops. These reforms led to an overall rise in intern satisfaction (50% vs 75.4%, p=0.02).Conclusion: Periodic restructuring of an existing program helps to improve the work-based learning experience and overall satisfaction among interns. This not only maximizes learning but also eases interns into their postgraduate life and workload subsequently enabling them to become more competent and well-rounded health practitioners.

1275-PUB: Call to Action: COVID-19 Pandemic Prompts Subcutaneous Treatment Option for Diabetes Ketoacidosis (DKA) in Hospital

COVID-19 challenges organizations to modify approaches to optimize diabetes management while reducing Personal Protective Equipment (PPE) use and nurse time, and maintaining patient safety. In April 2020, Scripps Health, a five-hospital health system in southern California created a subcutaneous Diabetes Ketoacidosis (DKA) treatment option for use with adults, admitted with mild to moderate DKA. Primary aims were to achieve DKA resolution and glycemic targets similar to the intravenous (IV) insulin treatment option, and no hypoglycemia &amp;lt;70 mg/dL. The new order set utilized weight-based dosing, with similar orders for labs, electrolyte and IV fluid replacement, and resolution criteria. Differences included automatic insulin dosing and basal/bolus insulin. Key changes were a reduced frequency of point of care testing (POCT) and ≤140 mg/dL hypoglycemia prevention orders. Post-implementation audits between April - July 2020 showed no hypoglycemia and resolution time similar to IV insulin. However, only 6% (N=17) of DKA cases were managed with subcutaneous, as compared to IV insulin. To help understand why there was such a limited uptake, a detailed retrospective chart review was undertaken on a subset of twenty-two DKA cases managed with IV insulin. Findings showed that 17 (77%) had type 2 diabetes, 5 (23%) had type 1 diabetes. 47% of cases had opportunities for subcutaneous management based on DKA classification and no contraindications for subcutaneous therapy. Findings indicate organizations should consider a DKA subcutaneous option. Lack of knowledge of DKA severity may be a factor in low utilization, therefore an EHR DKA Classification tool was implemented to support providers. Research is needed to determine if this increases utilization of the subcutaneous treatment option and what other barriers exist. Disclosure D. Meehan: None. L. Talavera: None. A. Philis-tsimikas: Advisory Panel; Self; Bayer Inc., Lilly Diabetes, Medtronic, Novo Nordisk, Consultant; Self; Sanofi-Aventis, Employee; Spouse/Partner; Ionis, Other Relationship; Self; Merck &amp; Co., Inc., Research Support; Self; Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk, Sanofi-Aventis. A. L. Fortmann: None.

Primary open angle glaucoma management in a tertiary eye care center in Saudi Arabia: a best practice implementation pilot project.

Primary open angle glaucoma (POAG) is a leading cause of permanent visual loss affecting significant numbers in Saudi Arabia. There is no cure for glaucoma but there is mounting evidence to guide ophthalmologists in diagnosing and managing this disease. The aim of this pilot project was to assess the compliance with evidence-based criteria and to implement an adapted clinical practice guideline (CPG) for the management of patients with POAG at a tertiary eye care center in Riyadh, Saudi Arabia that will lead to improving quality, consistency and optimizing patients' care. The project consisted of three phases using audit and feedback strategy. It has utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. Eleven evidence-based audit criteria were developed. A baseline audit was then conducted. Barriers behind areas of noncompliance were identified and a number of strategies were implemented to overcome them. A follow-up postimplementation audit was then conducted. Twenty electronic medical files were randomly selected for baseline audit. The results of the audit have identified a number of possible areas to improve in the diagnosis and management of POAG in compliance with the adapted CPG with compliance rate as low as 20% (4/20) in some criteria. Multifaceted interventions were implemented targeting mainly attitude and lack of knowledge and time and resource barriers. Significant improvement occurred in most criteria audited postimplementation. The project demonstrates that audit and feedback is a feasible and effective tool to change glaucoma practice in a teaching hospital in Saudi Arabia. The success was due to multifaceted interventions including clear communication to promote awareness, an easily accessible CPG, and regular reminders to improve knowledge and change behavior. We propose our pilot implementation to be generalized to promote implementing evidence-based ophthalmology.

The effects of implementation of a stepwise algorithmic protocol for nutrition care process in gastro-intestinal surgical children in Pediatric Intensive Care Unit (PICU).

Malnutrition is known as one of the major health problems among critically ill children; optimum nutrition support is considered as a therapeutic strategy to improve clinical outcomes and minimize the length of Pediatric Intensive Care Unit (PICU) staying as well as its costs. Implementation of an algorithmic protocol can result in the upgrade of the quality of nutrition support system in PICU. In this study, we developed a stepwise algorithmic nutrition care protocol for PICU patients in two phases as follows: a critical review of past literature and an expert discussion panel. The final structured protocol includes three following steps for the nutrition care process: 1) Initial nutrition screening and assessment, 2) Nutritional intervention and 3) Nutritional monitoring. Pre and post-implementation audits were carried out in a 23 bed medical/surgical PICU in a children's hospital affiliated to Mashhad University of Medical Sciences over two 4-week periods to evaluate the impact of the algorithm implementation. The post-implementation audit was performed by passing 12 weeks from the protocol implementation. Critically ill children aged between 1month and 10 years, and PICU length of stay>24h who were in post gastrointestinal surgery state, were enrolled. Totally, 34 eligible critically ill gastrointestinal surgical children in post-implementation audit were compared with 30 patients with similar eligibility criteria in the pre-implementation audit. Notably, there were no significant differences in gender, median age, length of PICU stay, and mechanical ventilation requirement in the two audits. The comparison of our pre and post-implementation audits showed a significant increase in the proportion of energy delivery goal achievement following performing our intervention (56.7%, and 85.3%, for pre and post-implementation audits, respectively; p-value=0.01).Additionally, time of achieving energy and protein goals were significantly decreased (5.5 vs. 3 days; p-value=0.008 and 4 vs 3 days; p-value=0.002, for energy and protein delivery goal achievements, respectively). The implementation of the algorithm have significantly improved the adequacy ratio of energy delivery and also decreased the time to achieve the goal in energy and protein intake among critically ill children in post-gastrointestinal state. In this regard, further prospective studies are needed for continuing the evaluation of the algorithm implementation outcomes in critically ill children with different surgical and internal underlying diseases.

Improving care for thalassemia patients in line with best practice standards at a tertiary referral cancer care center.

Beta-thalassemia major is a chronic hematological disorder that requires life-long management. This project aimed to improve thalassemia patients' care through the implementation of best practice standards at a tertiary referral cancer care center. The current project utilized a clinical audit design. A pre and post-implementation audit was carried out following best practice standards for patients with thalassemia. Chart review of nine thalassemia patients was undertaken pre and post-implementation of staff education, local clinical guidelines, and an annual care plan to manage thalassemia to determine adherence to best practice standards. Data were collected between June 2019 and June 2020 at a specialist outpatient and day treatment unit located in inner Brisbane, Australia. The pre-implementation audit results showed low compliance to the audit criteria, with the exception of nursing staff education. Following the implementation of strategies to align current care with evidence-based recommendations, the post-implementation audit showed improvement across all areas. Overall, implementation strategies were successful in improving patient care for thalassemia patients by 100%. Staff thalassemia education increased from 45 to 92%. Implementing an individualized treatment plan and thalassemia-specific nursing documentation as well as developing local clinical guidelines and providing targeted nurse education were effective strategies to improve care for thalassemia patients in line with best practice standards.

Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project.

Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.

O013 / #557: LIBER8 GLASS GOALS PROJECT: A NOVEL METHOD FOR ENSURING DAILY, INDIVIDUALIZED PATIENT-GOAL SETTING AND TEAM COMMUNICATION.

Aims & Objectives: Daily goals checklists have been shown to improve patient care and team communication in the critical care setting. Institutional surveys showed that staff found previous checklists ineffective. The objective of this study was to evaluate a novel daily goals checklist using the glass door of the patient rooms, as an easily visible communication tool, to set patient goals and track progress in a Pediatric Intensive Care Unit (PICU). Methods: We used the Pronovost’s 4 E’s model (Engage, Educate, Execute, and Evaluate) to implement the Glass Goals. The Glass Goals are a template on patient doors, for goal setting in specific domains of sedation, breathing, circulation, diet, early mobilization, fluids, and family goals. Content was created in collaboration with PICU staff, leadership, and families, and rolled out over 1 month. Goal setting and team communication were assessed using pre- and post-implementation rounding audits and surveys, and a post-implementation uptake assessment.Results: Pre-implementation rounding audits on 49 patients found the frequency of goal setting was 40.2% across all domains excluding family goals. Median rounding time was 11:46 (IQR = 8:25). Post-implementation, Glass Goals completion was 94.6% (N = 74). Post-implementation surveys and rounding audits are ongoing. Conclusions: Preliminary analyses indicate that implementation of the Glass Goals leads to improved uptake of patient goal setting and team communication. Future analyses will assess post-implementation goal setting during rounds, rounding time, and perceptions of the Glass Goals by parents and HCPs using surveys. Acknowledgements: Hannah Zimmerman, Grace Lamond, Data Collection Assistants; McMaster Family Advisory Council; Dr. Samara Zavalkoff

Reducing the incidence of phlebitis in medical adult inpatients with peripheral venous catheter care bundle: a best practice implementation project.

One major complication of the insertion of a peripheral venous catheter (PVC) is phlebitis, often resulting in delay of treatment, increased healthcare costs and prolonged hospitalization. The current study sought to evaluate the effectiveness of a standardized PVC care bundle in increasing the compliance of PVC care and assessment and reduce the occurrences of phlebitis rates. A pre and postimplementation audit approach was used in this study and adopted the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice program. This study was carried out in three phases over a 10-month period, from March 2017 to December 2017 across three medical wards in a hospital in Singapore with a sample size of 90 patients. The study involved educating nurses on phlebitis assessment, implementing a PVC care bundle and monitoring compliance. An audit tool comprising four criteria from the Joanna Briggs Institute Practical Application of Clinical Evidence System was developed. One-month and 3-month postimplementation findings revealed significant improvement in Criteria 1, 3 and 4 (P < 0.001) but no significant improvement in Criterion 2 (P > 0.05). Six-month postimplementation findings showed significant improvement in all four criteria (P < 0.05). An interesting finding was that the number of reported occurrences of phlebitis increased after implementing the PVC care bundle. The increase in phlebitis rates could be attributed to the care bundle facilitating prompt and early identification of phlebitis. Despite the initial increase in occurrences 1 month post implementation, the general effectiveness of the care bundle in reducing occurrences of phlebitis was seen 6 months post implementation. The effectiveness of the care bundle to reduce phlebitis rates may be even more evident across a longer implementation period. The current study showed that the implementation of a standardized PVC care bundle can significantly enhance the assessment and identification process of phlebitis and can aid in reducing the incidence of phlebitis. The nurses' compliance in practicing the PVC care bundle was determined by the post and preimplementation audits, thus, the audit approach was beneficial in translating evidence into practice.

Clinical Team Training and a Structured Handoff Tool to Improve Teamwork, Communication, and Patient Safety.

Effective communication among healthcare teams is essential for ensuring handoff-related safety and quality care outcomes. The aim of this project was to improve patient safety through the reduction of communication-related errors on an acute hemodialysis unit (AHU) in an academic medical center. A target was set to reduce by 50 percent the communication-related errors using strategies to improve teamwork and communication. Acute hemodialysis unit team members attended Clinical Team Training (CTT) informational sessions on teamwork and communication. A structured handoff tool was implemented in the AHU to improve nurse communication and reduce communication-related patient safety events. Descriptive statistics and comparison of means were conducted to assess the differences between preimplementation and postimplementation audit and safety event data. There was a statistically significant difference between the preintervention and postintervention groups of handoff tool usage and completion as well as a consistent decrease in handoff-related safety events after implementation. Findings suggest that CTT and a structured handoff tool used to guide nurse-to-nurse care transitions lead to a reduction in communication-related safety events during handoffs in an AHU.